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The
ethics and effectiveness of Community treatment orders (CTOs) has always been a
subject of intense international debate.
The first UK-based scientific trial
evaluating its effectiveness finds that CTOs fail to cut hospital readmission
rates in mental health patients; they rather curtail patients' liberty.

A
community treatment order allows an eligible patient with psychosis to leave
the hospital and get treated in the community.
Patients are however required to accept clinical monitoring and allow rapid
recall for assessment. Doctors and
approved mental health professionals are granted powers to impose strict
supervised community treatment on mental health patients. This system has been widely introduced in the USA,
Australia, some Canadian provinces, the UK, and several other European
countries. This aimed
at reducing the involuntary hospitalisation of patients with mental illness.

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Severe opposition always followed the system of
CTOs, because in a sense, patients discharged under CTOs had a 'restricted'
version of liberty. Discharge under CTOs could happen only after getting the
approval of a responsible clinician (usually a psychiatrist) and an approved
mental health professional. Only those patients who comply with certain
conditions would be allowed to stay in the community. Patients who fail to
comply would be recalled to the hospital.

There was no experimental evidence to prove the
superiority of CTOs over the existing provision for "leave of absence" under Section 17.
Section 17 allows a patient to leave hospital for some hours or days, or even
exceptionally weeks, while still subject to recall. This was a means to assess
recovery before granting voluntary status. Section 17 may be viewed as an older and "less restrictive" form of supervised
community treatment.

A UK-based randomised controlled trial
compared the outcomes of patients discharged under CTOs with patients
discharged under section 17 leave. Researchers postulated that discharge
under CTOs would be associated with a lower rate of readmission
than those discharged on the pre-existing Section 17 leave of absence. The proposition proved this wrong.

The imposition of compulsory supervision failed to
reduce the rate of readmission of psychotic patients. No evidence that could justify
'the
significant curtailment of patients' personal liberty' could be obtained from the trial. In light of
findings from this trial, the age-old debate over ethics and effectiveness of use of Community
Treatment Orders are once again active.

The trials conducted are however not fool proof,
but implications of this report need careful consideration.

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